Received 07/22/2018 Review began 07/22/2018 Review ended 07/22/2018 Published 07/24/2018

© Copyright 2018Nagaraj et al. This is an open accessarticle distributed under the terms of theCreative Commons Attribution LicenseCC-BY 3.0., which permits unrestricteduse, distribution, and reproduction in anymedium, provided the original author andsource are credited.

Recurrent Peritoneal Pseudocyst: A RareComplication of Peritoneal DialysisSavitha Nagaraj , Muhammad H. Khan , Farzana Afroza

1. Internal Medicine, The Brooklyn Hospital Center, Brooklyn, USA 2. Geriatrics/Internal Medicine/The BrooklynHospital Center, The Brooklyn Hospital Center, Brooklyn, USA

Corresponding author: Savitha Nagaraj, savitha.vnagaraj@gmail.com

AbstractAn alarming 468,000 people are dependent on dialysis for their end-stage renal disease (ESRD) managementin the United States alone. Peritoneal dialysis is a preferred type of dialysis over hemodialysis, consideringits initial survival advantage, patient satisfaction, and cost-effectiveness. One of the rare complications ofperitoneal dialysis is abdominal and peritoneal pseudocyst formation. Literature regarding the accuratemedical management of such peritoneal pseudocysts is scarce. Adding to this, management of recurrentloculated, non-malignant peritoneal pseudocyst poses to be challenging especially when pseudocysts recurafter the offending peritoneal dialysis catheter is removed.

We report one such case of a patient with a history of ESRD managed on long-term peritoneal dialysis. Hepresented to the hospital with recurrent abdominal pain which was treated multiple times for spontaneousbacterial peritonitis. Due to recurrence, his peritoneal dialysis was discontinued and hemodialysis wasinitiated. While on hemodialysis and two years after peritoneal dialysis catheter removal, he presented withsudden onset abdominal distension. Imaging showed loculated peritoneal pseudocyst with multipleloculations. Standard recommendation of surgical removal of cyst could not be performed in this patient dueto his coexisting medical co-morbidities. Interventional radiology (IR) guided cyst drainage was attemptedbut was limited due to multiple locutions. However, IR drainage proved to provide temporary relief and afterrepeated IR guided drainage, a temporary drainage tube was placed. This subsided the recurrence of fluid-filled pseudocysts and the patient improved.

This case emphasizes the importance of follow up of patients who have been or currently are on peritonealdialysis for early recognition of late-onset complications. Our case also shows the routine challenges facedby the clinician when rare complications arise and standard treatment options cannot be applied.

Categories: Internal Medicine, Gastroenterology, NephrologyKeywords: delayed complication, spontaneous bacterial perio, ascitis, peritoneal dialysis, loculated peritonealpseudocyst, esrd (end stage renal disease), abdominal distension

IntroductionAccording to the National Kidney Foundation, 660,000 people are diagnosed with an end-stage renal disease(ESRD) and over 468,000 are on dialysis in the United States alone [1]. A substantial number of thesepatients are on peritoneal dialysis. Peritoneal dialysis is considered a superior option compared tohemodialysis especially with its increased initial survival advantage, patient satisfaction, and cost-effectiveness. Some of the well-known complications of peritoneal dialysis are leakage, peritonitis, andabdominal wall weakness. However, only a few cases of abdominal and peritoneal pseudocyst formation as acomplication of this form of dialysis are reported.

We report one such case of multiple recurrent peritoneal loculated pseudocysts, not responsive to routinemanagement, that occurred as a complication of peritoneal dialysis two years after the peritoneal dialysiswas discontinued. This case report will highlight the timeline of the development of the pseudocyst and thechallenges in the management of the recurrent pseudocyst in our patient. Our case also emphasizes theimportance of long-term follow up of patients on peritoneal dialysis for the development of complications.

Case PresentationA 68-year-old male with past medical history of ESRD on peritoneal dialysis, hypertension, hyperlipidemia,seizure disorder, left craniectomy was sent from his nursing home in 2013 for abdominal pain, decreasedappetite, lethargy, and low oxygen saturation. Examination revealed a cachectic male with tender distendedabdomen. Peritoneal dialysis catheter was visualized and the site was clean. He was suspected to havesubacute bacterial peritonitis secondary to peritoneal dialysis and was empirically treated with vancomycinand cefepime. Computed tomography (CT) of the abdomen and pelvis showed a small amount of free fluid inthe peritoneal cavity (Figure 1).

1 1 2

Open Access CaseReport DOI: 10.7759/cureus.3043

How to cite this articleNagaraj S, Khan M H, Afroza F (July 24, 2018) Recurrent Peritoneal Pseudocyst: A Rare Complication of Peritoneal Dialysis. Cureus 10(7): e3043.DOI 10.7759/cureus.3043

FIGURE 1: Computed tomography (CT) scan of the abdomen and pelvisshowing a small amount of free fluid in the peritoneal cavity

However, the peritoneal fluid analysis did not grow any organism. Peritoneal dialysis was temporarilydiscontinued and a temporary hemodialysis catheter was placed. He was later discharged on peritonealdialysis after his symptoms improved.

The patient presented with similar complaints in 2014 and a single-photon emission computed tomography(SPECT) gallium scan revealed abnormal activity in the right lower quadrant of abdomen and pelvis,suspicious for peritonitis. CT abdomen showed pneumoperitoneum and ascites, peritoneal fluid again didnot grow any organisms. Due to elevated leukocyte count and fever, the patient was empirically treated withantibiotics. He was readmitted in 2015 with similar complaints when interventional radiology (IR) guidedhemodialysis catheter was placed and peritoneal dialysis was permanently discontinued.

The patient presented two years after the discontinuation of peritoneal dialysis with massive abdominaldistension, abdominal pain, and vomiting. He was receiving hemodialysis at this time. Repeat CT scan ofabdomen and pelvis revealed massive abdominal and pelvic ascites with encapsulated complex pseudocystarising from the peritoneal membrane impinging on the liver (Figure 2).

2018 Nagaraj et al. Cureus 10(7): e3043. DOI 10.7759/cureus.3043 2 of 5

FIGURE 2: Computed tomography (CT) scan of the abdomen and pelvisrevealing encapsulated complex pseudocyst arising from the peritonealmembrane impinging on the liver

Ultrasound of the abdomen and pelvis showed multiple fluid-filled loculations present within the cyst(Figure 3).

2018 Nagaraj et al. Cureus 10(7): e3043. DOI 10.7759/cureus.3043 3 of 5

FIGURE 3: Ultrasound of the abdomen showing multiple fluid-filledloculations

The pseudocysts were suspicious for malignancy; however, IR guided drainage revealed chocolate brownfluid that was negative for malignant cells or organisms.

He presented three more times in the following four months with similar complaints. Surgical managementwith pseudocyst removal was considered but deferred due to the loculated nature of the cyst and patient’scomorbidities. Medical management with peritoneal drainage drained large amounts of fluids although theprocedure was limited by the loculations. The abdominal swelling decreased and the patient experiencedtemporary relief after every drainage. CT guided subcutaneous peritoneal drainage catheter was temporarilyplaced and the patient continued to improve. He continues to have occasional episodes of abdominaldistension secondary to fluid collection in the pseudocysts although the frequency of recurrence drasticallyreduced.

DiscussionPeritoneal dialysis, although a preferred method of dialysis in ESRD patients due to its many advantages, isalso associated with a few dangerous complications such as peritonitis and peritoneal pseudocysts.Peritoneal pseudocyst is a less well known but an uncomfortable and dangerous complication of peritonealdialysis associated with increased risk of recurrent peritonitis. Although there are reported cases ofperitoneal pseudocyst as a complication of the ventriculoperitoneal shunt, there are very few reported casesof peritoneal pseudocysts as a complication of peritoneal dialysis [2].

Precise pathophysiology of pseudocyst formation and standardized management guidelines of peritonealpseudocyst are currently scarce due to the limited number of known cases. In patients with peritonealdialysis, whether the pseudocyst occurs secondary to chronic irritation of the peritoneum or as a result ofrecurrent bacterial infection is unknown. Surgical removal of a symptomatic peritoneal pseudocyst isconsidered curative, but in cases such as our patient, surgical interventions are not an option due to therecurrent infections or other comorbidities that make the patients high risk for surgery. Alternativelydraining the cyst via CT guided intervention proved to be a viable option for our patient, although theprocedure was limited due to the loculated nature of the cyst.

2018 Nagaraj et al. Cureus 10(7): e3043. DOI 10.7759/cureus.3043 4 of 5

ConclusionsOur case report highlights some of the serious, recurrent complications of peritoneal dialysis and thechallenges that can be faced in diagnosing and managing these complications. The surprising and puzzlingaspect of this case is the time lag between discontinuation of peritoneal dialysis and the development ofperitoneal pseudocyst along with the unknown cause and mechanism of the development of pseudocyst. Inconclusion, it is important to educate and monitor patients currently or previously on peritoneal dialysis forthe development of delayed complications such as pseudocysts and adequately manage these challengingcomplications. Further studies are needed in this area to look into the pathophysiology and evaluate thecontributing factors for the development of peritoneal pseudocyst as a complication of peritoneal dialysis.

Additional InformationDisclosuresHuman subjects: Consent was obtained by all participants in this study. Conflicts of interest: Incompliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/servicesinfo: All authors have declared that no financial support was received from any organization for thesubmitted work. Financial relationships: All authors have declared that they have no financialrelationships at present or within the previous three years with any organizations that might have aninterest in the submitted work. Other relationships: All authors have declared that there are no otherrelationships or activities that could appear to have influenced the submitted work.

References1. Saran R, Li Y, Robinson B, et al.: US Renal Data System 2015 annual data report: epidemiology of kidney

disease in the United States. Am J Kidney Dis. 2016, 67:S1-305.https://www.ncbi.nlm.nih.gov/pubmed/26925525. 10.1053/j.ajkd.2015.12.014

2. Baer G, Wagner A, Selbach J, Otto M, Weiner SM: Abdominal pseudocysts following peritoneal dialysis-associated peritonitis: a report of 3 cases. Am J Kidney Dis. 2010, 55:e15-e19.https://www.ncbi.nlm.nih.gov/pubmed/20338461. 10.1053/j.ajkd.2009.12.019.

2018 Nagaraj et al. Cureus 10(7): e3043. DOI 10.7759/cureus.3043 5 of 5